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Carrier Agreements

Valley Health Plan California

Application Agreement

All applicants and dependents age 18 or older must read and sign below. If the primary applicant is younger than 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copayments, coinsurance, and deductibles for all the applicants listed on this form.

APPLICANT AGREEMENT

All faxed and mailed correspondence must be signed and dated by the applicant or someone legally authorized to act on his or her behalf. The applicant of his or her authorized representative may request a copy of the completed application. For more information, please call VHP Sales & Broker Relations at 408.885.3560.

Important: Required signatures-all applicants age 18 or over must sign and date below on the appropriate signature line. A parent or legal guardian must sign for family members under the age of 18. If signatures are missing, we cannot process the application.

By signing below you are attesting to the following:

  • I have provided true and correct answers to all the questions on this form to the best of my knowledge, and

  • I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as required by law, and

  • I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, disability, age, sex, sexual orientation, gender identity, or religion. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file or www.healthhelp.ca.gov or www.dfeh.ca.gov

  • I know all benefits received must be provided or authorized by VHP, and

  • I know that VHP is authorized to obtain and release medical information in compliance with the insurance information and Privacy Protection At, Section 791 et. Seq. of the California Insurance Code, and

  • I , and the persons listed, will abide by the provisions of the Individual & Family Plan; and • I, and the persons listed, are not eligible nor are enrolled in any other health insurance plan (including Medicare); and

  • I will inform VHP upon such eligibility.

ACKNOWLEDGEMENTS AND SIGNATURE

By submitting an electronic application; entering your name in the signature section has the same legal significance as an original signature.